Basic Information
| Provider Information | |||||||||
| NPI: | 1861424319 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOTILLO | ||||||||
| FirstName: | RODRIGO | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 632040 | ||||||||
| Address2: | |||||||||
| City: | NACOGDOCHES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759632040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365605668 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1309 S UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | NACOGDOCHES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759616486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365605668 | ||||||||
| FaxNumber: | 2146458601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 04/11/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | J5488 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1388985-14 | 05 | TX | MEDICAID | 138898513 | 05 | TX | MEDICAID | 8X0056 | 01 | TX | BCBS | OTHER |